I am located in Suisun - Davis Pre-Dental Society - · PDF fileJessica Nelson and I am your local Air Force Health Professions Career Advisor. I am located in Suisun City, ... Form

Thank you for your interest in the United States Air Force Dental/Medical Corps Scholarship. My name is Jessica Nelson and I am your local Air Force Health Professions Career Advisor. I am located in Suisun City, CA. If you are receiving this e-mail, you are either seeking more information concerning the Air Force's Dental/Medical Corps Scholarship, or you are ready to move forward with the application process. The application process is often perceived as complicated and lengthy but it actually can be done quite fast! To assist you in this process, I have developed this application guideline to keep you on track of meeting your goal and getting to the Scholarship Selection Board. Your commitment to the timeline we establish together is vital to your application completion and ultimately your selection as a US Air Force Officer.

I have listed below the steps and items needed to complete your application.

If you are missing any part of these steps, please contact me ASAP. For a completed application, the Air Force requires a qualifying medical physical (exam), Non-Derogatory Credit Check, a Background Investigation and an Interview with a Dental Officer in the Air Force (Dental HPSP only).

1st - Scroll Document requirements (Complete within 3 business days from date requested): **Note: Every potential Officer candidate must be Senate approved and the items below will initiate that process.

x Copy of Social Security Cardx Copy of Driver’s Licensex Copy of Birth Certificate (Naturalization Certificate or Resident Card)x Copy of Marriage Certificate or Divorce Decreex DD 214 or DD 368 Conditional Release (Prior Service applicants)

2nd – Applications (Complete within 5 business days from date requested): x DD Form 2807-2 (MEDICAL PRESCREEN Form)- if you have any YES answers, all medical

records pertaining to the YES answerx USMEPCOM 680 Request for Examination Form- complete to the best of your knowledge and ONLY sign

on Block 25. f. If you do not have health insurance and a medical provider, sign blocks 26-29 also. All other forms (AF Form 2030, AFRS IMT 1325, AFRS Tattoo Form 4428, DD Form 2983, and AFRS Form 6C

3rd - Other required (complete within 10 business days from date requested): x (N/A for MATRIX applicants, see note*): (3) Letters of recommendation ** Ask that they send directly to me

either E-mail or mail. They can be from professors, supervisors, physicians, dentists, etc. Make sure to specify that they need to be on letterhead and signed.

x ALL Official College Transcripts from any and all schools attended *MUST BE SENT TO ME FROMTHE SCHOOL* (cannot be student issued)

x MCAT/DAT Scores- can be web printoutx (N/A for MATRIX applicants*) Applicant Questionnairex (N/A MATRIX applicants*) Medical/dental school acceptance letterx SF86 National Security Positions Paperworkx AFRS 1413 verification of scheduled graduation (required if currently enrolled in college). I will

provide if needed.

Options for sending in documents:Secure File Exchange Website: https://safe.amrdec.army.mil/safe/Default.aspxUSPS:

Fax (when faxing, also send me a courtesy e-mail): 707-423-4063E-mail: [email protected]

Air Force Health Professions ATTN: TSgt Jessica Nelson 333 Sunset Ave Ste 200 Suisun City, CA, 94585

I look forward to working with you on your application and please do not hesitate to ask if you need assistance on any form! Jessica Nelson

707-494-9034

x

*To qualify as a MATRIX applicant, you must hold an undergrad GPA of 3.4 or higher, and an MCAT of 503/29 with a minimum of 123's and 8's in each subsection

Note for MATRIX APPLICANTS

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13. PROFICIENT IN FOREIGN LANGUAGE (X One)(If Yes, specify) [ ] YES [ ] NO

15. PLACE OF BIRTH (City, State, and Country)

11. RELIGIOUS PREFERENCE (Optional)

FOR USE OF THIS FORM, SEE USMEPCOM REG 680-3 THE INFORMATION PROVIDED CONSTITUTES AN OFFICIAL STATEMENT

FOR OFFICIAL USE ONLY

A. SERVICE PROCESSING FOR

RIGHT THUMBPRINT, FIRST ATTEMPT(AFFIX THUMBPRINT WITH THUMBNAILPOINTED TO THE LEFT)

IF SECOND ATTEMPT IS REQUIRED,TURN FORM OVER (TOP OF FORM ONTHE BOTTOM) AFFIX RIGHTTHUMBPRINT ON UPPER RIGHT CORNER, THUMBNAIL POINTED TO THE LEFT

24. RIGHT THUMBPRINT

30. CERTIFICATION BY RECRUITING PERSONNEL I certify that I have properly identified this applicant in accordance with my service directives, have reviewed for completeness and accuracy the information provided on this form, and have witnessed the applicant's signature:

_________________________________________________________________/__________________________________________________/_____________________________ (Signature of Recruiter (or rep, if auth)) (Printed/Typed Name of Recruiter or Rep) (Date)

_________________________________________________________________ (Printed/Typed Name of Recruiter (if not recorded above))

____________________________________________________/____________________________________________/_____________________________________________(Recruiter ID/SSN) (Local Recruiting Activity) (Bn, NRD, Sq or RS Location)

USMEPCOM Form 680-3A-E, OCT 05 Replaces USMEPCOM Form 680-3A-E, DEC 03, which is obsolete

25. APPLICANT CERTIFICATION IN PRESENCE OF RECRUITING PERSONNEL I certify that I am the person identified on this form and the information about me shown there, including my Social Security Number is all true and correct to the best of my knowledge. I also certify that:

a. I have never been tested ANYTIME or ANYWHERE with the ASVAB either for enlistment purposes or as a student under the ASVAB testing program.

b. I was tested with the ASVAB on or about _________________________________________ at ___________________________________________(Most Recent Date Tested) (School, City, and State)

c. Request for student test scores (high school look-up) _________________________________________ at ___________________________________________(Most Recent Date Tested) (School, City, and State)

d. Yes, I want to keep my AFQT scores from the student test listed in "c" above.

e. Current or last high school attended ____________________________________________ / _____________________________________________________________ (High School) OR (13 Digit Code)

f. _________________________________________________________/________________________________________/_______________________________________________ (Signature of Applicant) (Social Security Number) (Date)

23. APPLICANT CERTIFICATION IN PRESENCE OF TEST ADMINISTRATOR I certify that I am the person identified on this form:

____________________________________________________________________ (Signature of Applicant)

PRIVACY ACT STATEMENT AUTHORITY: Sections 505, 508, 510, and 3012 of Title 10 U.S. Code and Executive Order 9397. PRINCIPAL PURPOSE: The requested information on this form will be usedto properly process and identify the individual requesting an examination at a military entrance processing station (MEPS). ROUTINE USE: Record is maintained with other enlistment processing records. DISCLOSURE: Voluntary; refusal to provide required data could result in denial of enlistment.

B. PRIOR SERVICE [ ] YES [ ] NO

NUMBER OF DAYS:

C. SELECTIVE SERVICE CLASSIFICATION D. SELECTIVE SERVICE REGISTRATION NUMBER

1. SOCIAL SECURITY NUMBER 2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc.)

3. CURRENT ADDRESS (Street, City, County, State, Country, ZIP Code)

4. HOME OF RECORD ADDRESS (Street, City, County, State, Country, ZIP Code)

5. CITIZENSHIP (X One) 6. SEX (X One) 7.a. RACIAL CATEGORY (X one or more)

a. U.S. AT BIRTH (If this box is marked, also X (1) or (2))

(1) NATIVE BORN

(2) BORN ABROAD OF U.S. PARENT(S)

b. U.S. NATURALIZED

c. U.S. NON-CITIZEN NATIONAL

d. IMMIGRANT ALIEN (Specify)

e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

a. MALE

b. FEMALE

9. NUMBER OF DEPENDENTS

(1) AMERICAN INDIAN/ ALASKA NATIVE

(2) ASIAN

(3) BLACK OR AFRICAN AMERICAN

(5) WHITE

7.b. ETHNIC CATEGORY (X One)

12. EDUCATION (Yrs/Highest Ed Gr Completed)10. DATE OF BIRTH (YYYYMMDD)

14. VALID DRIVER'S LICENSE (X One) [ ] YES [ ] NO (If Yes, list State, number, and expiration date)

21. APPLICANT'S SIGNATURE 22. MIRS CODING

WKID ST DATE INT DATE INT

17. a. RECRUITER ID/SSN b. STATION ID

20. MEDICAL: a. MEPS MEDICAL EXAM REQUIRED TO ENLIST? (X One) [ ] YES [ ] NO

18. TEST ADMINISTRATOR SSN/ID 19. TEST ADMINISTRATOR SIGNATURE

(1) HISPANIC OR LATINO

(2) NOT HISPANIC OR LATINO

16. APTITUDE: a. ASVAB REQUIRED TO ENLIST? (X One) [ ] YES [ ] NO b. ENLIST UNDER STUDENT TEST SCORES?

(X One) [ ] YES [ ] NO

c. TEST TYPE[ ] INITIAL[ ] SPECIAL[ ] CONFIRMATION

e. PREVIOUS TEST VERSIONS 1. 2.

f. PREVIOUS TEST DATES (YYYYMMDD)1. 2.

c. DATE LAST FULL MEDICAL EXAM (YYYYMMDD)

b. EXAM TYPE [ ] FULL [ ] SPECIAL [ ] RE-EXAM

[ ] INSPECT [ ] CONSULT [ ] OTHER

MEDICAL RECORDS RELEASE AUTHORITY: I request and authorize individuals/organizations listed below to release to the MEPS a complete transcript of my medical records. This release is for the purpose of further evaluation of my medical acceptability under military medical fitness standards. The medical records are to be obtained by thisexaminee at no cost to the Government and made available for review during the pre-enlistment physical.

26. APPLICANT'S CURRENT MEDICAL INSURER NAME(If none, sign your complete name to affirm you have no current medical insurer):

27. APPLICANT'S CURRENT MEDICAL PROVIDER NAME (If none, sign your complete name to affirm you have no current medical provider):

29. MEDICAL PROVIDER ADDRESS(Street, City, State, Country, ZIP Code)

28. MEDICAL INSURER ADDRESS(Street, City, State, Country, ZIP Code)

APPLICANT SSN

Photo ID? (X One) [ ] YES [ ] NO

If yes, type/organization __________________________________

ID Number ______________________________________________

(4) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

f. ALIEN REGISTRATION NUMBER (As applicable)

REQUEST FOR EXAMINATION

8. MARITAL STATUS(Specify)

1st 2nd

d. RETEST TYPE[ ] 1ST RETEST [ ] 6 MONTH RETEST[ ] 2ND RETEST [ ] IMMED RETEST AUTHORIZED

INSTRUCTIONS FOR COMPLETING DD FORM 2807-2, ACCESSIONS MEDICAL PRESCREEN REPORT

1. This form is to be completed by each individual who requires medical processing in accordance with Department of Defense Instruction (DODI)6130.03, "Physical Standards for Appointment, Enlistment, or Induction" and DODI 1304.02, "Accession Processing Data Collection Forms." This form must be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed.

6. MEPS Chief Medical Officers (CMOs) may locally modify the above instructions and instruct recruiters on what supporting medical documents theyrequire to complete the DD Form 2807-2 medical prescreen review, if doing so enhances the efficiency of medical processing and is consistent with DODI 6130.03 and USMEPCOM guidance.

7. If all attempts to obtain required substantiating and supporting medical documents fail, the recruiter must contact the MEPS medical department forguidance prior to submitting an incomplete medical prescreen packet.

2. Replaces the existing medical prescreen form (DD Form 2807-2, AUG 2011). Additional questions have been added to improve its usefulness tothe accessions medical pre-screening process. The questions are intended to provide the U.S. Military Entrance Processing Command (USMEPCOM) with health history information necessary to identify conditions commonly related to medical causes for separation during basic and follow-on training (per P.L. 105-85, Div. A, Title V, S 532).

3. Use of medical history information facilitates efficient, timely, and accurate medical processing of individuals applying for Service in the UnitedStates Armed Forces or United States Coast Guard. Positive responses do not automatically result in disqualification but are necessary to prompt further explanation that will be used to determine medical qualification.Medical history information assists USMEPCOM medical personnel in the medical prescreening of applicants. Accurate responses to all questions are critical and all positive responses must be fully explained. Applicant responses to questions may be verified using electronically obtained medical history by the USMEPCOM. Medical history information will be used by the Department of Defense for continuity of care purposes if and when an applicant accesses into the Armed Forces or Coast Guard. Supporting medical information in the form of historical medical records may also be attached to the Service member's medical record. Medical history information collected by the USMEPCOM during accession medical processing will serve as the foundation for a Service member's lifecycle medical treatment record.

4. The completed DD Form 2807-2 along with all substantiating and supporting medical documents must be delivered to USMEPCOM for review priorto scheduling the applicant for medical examination. All documents must be submitted for review in accordance with standards below. After review, the MEPS will notify the Recruiting Service of the applicant's status.

- 1 processing day prior for applicants with no positive medical history (all items marked "NO" with the exception of items 9 (glasses/contacts), 11 (defective color vision), and 20 (braces) which can be "YES").

- 2 processing days prior; for applicants with ANY positive medical history (other than those noted above) and 5 OR LESS single-sided pages of supporting medical documents.

- 3 processing days prior; for applicants with ANY positive medical history (other than those noted above) and MORE THAN 5 single-sided pages of supporting medical documents.

Secure electronic submission is preferable; if not feasible bring/mail to the nearest Military Entrance Processing Station (MEPS) which can be found at http://www.mepcom.army.mil/battalions/index.html . All supporting medical documentation must be present with the DD Form 2807-2 to meet the above timeframes for review. After review by a USMEPCOM provider, appropriate processing notification will be made.

5. If an applicant has been seen by any health care provider (HCP) and/or has been hospitalized for any reason, medical records/documentation mustbe obtained and submitted along with a medical release to USMEPCOM. Provide all medical documents via secure electronic submission (if possible) to the nearest MEPS. If hand-carried or mailed ensure they are sealed in an envelope marked: "CONFIDENTIAL: MEPS MEDICAL DEPARTMENT".

a. If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private medical doctor/healthcare provider including:

(1) office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and record of date when released from care to full, unrestricted activity; (2) emergency room (ER) report(s); (3) study reports (e.g. x-ray, magnetic resonance imaging (MRI), Computerized Tomography (CT), etc.); (4) procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.); (5) pathology reports (e.g., tissue specimens sent to lab for microscopic diagnosis, abnormal PAP smear cytology, etc.); (6) specialty consultation records (e.g., neurologist, cardiologist, OB/GYN, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).

b. If the applicant was hospitalized, obtain a copy of the inpatient hospital record, to include (if any): ER report, admission history and physical,study reports, procedure reports, operative report (example: surgery to bone or joint), pathology report, specialty consultation reports, and discharge summary.

c. If an applicant has been diagnosed or treated for any attention disorder (Attention Deficit Disorder (ADD), Attention Deficit HyperactivityDisorder (ADHD), etc.), academic skills or perceptual defect, or had an Individualized Education Plan or 504 Plan, call/contact the MEPS medical department for additional instructions.

d. Obtain any and all documents relating to any evaluation, treatment or consultation with a psychiatrist, psychologist counselor, or therapist, on aninpatient or out-patient basis for any reason, including but not limited to counseling or treatment for adjustment or mood disorder, family or marriage problems, depression, treatment or rehabilitation for alcohol, drug, or substance abuse.

DD FORM 2807-2, MAR 2015 PREVIOUS EDITION IS OBSOLETE. Page 1 of 7 PagesAdobe Designer 9.0

ACCESSIONS MEDICAL PRESCREEN REPORTOMB No. 0704-0413 OMB approval expires Oct 31, 2017

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. PRIVACY ACT STATEMENT

AUTHORITY: PRINCIPAL PURPOSE(S):

10 U.S.C. 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSN).To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants

and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.ROUTINE USE(S): DoD Blanket Routine Uses found at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspxapply to this use of this data.DISCLOSURE: Voluntary, however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application

status.to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or $10,000 fine,or both), to anyone making a false statement. If you are selected for enlistment, commission or entrance into a commissioning program based on a false statement, you may be subject to prosecution under the Uniform Code of Military Justice or to administrative separation proceedings for discharge, and could receive a less than honorable discharge."

4. SOCIAL 3. DATE OF BIRTH (YYYYMMDD)1. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

5. HEIGHT (inches) 9. DATE (YYYYMMDD)

12. USUAL OCCUPATION

8. SERVICE AND COMPONENT (X as applicable)

10. PURPOSE OF EXAMINATION (X as applicable) 11. POSITION (If a current Federal Employee)(Job Title, Grade, Component)

7. MAX WEIGHT(lbs.)

6. WEIGHT (lbs.)

2. AGESECTION I - APPLICANT

SECTION II - MEDICAL HISTORY. Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III (Pages 4 and 5).

Army

Enlistment U.S. Service Academy

(Specify)

1. Double vision

8. Any other eye condition, injury or surgery

10. Loss of vision in either eye11. Color vision deficiency or color blindness

7. Strabismus or "lazy eye" or any surgery to correct these

6. Glaucoma5. Night blindness4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)3. Cataracts or surgery for cataracts2. Detached retina or surgery to repair a detached retina

USMC Regular

CURRENTLY HAVE OR ANY HISTORY OF:EYES

22. Asthma

27. Used inhaler(s) or steroids for breathing problem(s)

30. History of chest, chest wall, or breast surgery

29. Collapsed lung or other lung condition28. Chronic cough or frequent coughing at night

26. Other breathing problems worsened by exercise, weather,pollens, etc.

25. Bronchitis24. Shortness of breath23. Wheezing

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM

21. Tooth or gum problems (other than cavities)

12. Perforated ear drum or tubes in ear drum(s)

14. Loss of balance or vertigo

13. Ear surgery, to include mastoidectomy or repair ofperforated ear drum

EARS

31. Heart murmur, valve problem or mitral valve prolapse

36. Any other heart problems35. An abnormal electrocardiogram (EKG)34. Pain or pressure in the chest

33. Heart surgery32. Palpitation, pounding heart or abnormal heartbeat

HEART

37. Stomach, esophageal or intestinal ulcer

45. Rectal disease, hemorrhoids, or blood from the rectum

47. Bariatric surgery (weight loss surgery)46. Hemorrhoid surgery

42. Rupture/hernia

44. Chronic or recurrent intestinal problem of the small or largebowel such as Irritable Bowel Syndrome, Crohn's disease,Ulcerative Colitis, or Celiac disease

43. Surgery to remove or repair a portion of the intestine orspleen (other than the appendix)

41. Jaundice (except neonatal) or hepatitis (liver disease)40. Gall bladder trouble or gallstones39. Frequent indigestion or heartburn38. Difficulty swallowing

ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM

15. Hearing loss or wear a hearing aidHEARING

16. Ear, nose, or throat trouble including tonsillectomy

19. Any surgery of your face, mandible or jaw18. Absence of, or disturbance of sense of smell

17. Chronic sinus infections or recurrent nose bleeds

NOSE, SINUSES, MOUTH, AND LARYNX

9. Worn/wear contact lenses or glasses (Bring your contactlens kit and solution so you can remove contacts duringvision testing, or for best results remove 72 hours prior.Bring your eyeglasses no matter how old they are.)

VISION

20. Do you wear dental braces or plan to wear braces? (If so, yourorthodontist must submit a letter stating that active orthodontictreatment will be completed prior to active duty date: release form/sample format can be found in the Recruiter's Medical Guide.)

DENTAL

NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO

Page 2 of 7 PagesDD FORM 2807-2, MAR 2015

maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0413). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

CommissionRetention

ROTC ScholarshipOther

NavyUSAF

USCGOther:

Reserve ComponentNational Guard

.

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SOCIAL SECURITY NUMBER (Last 4)

SECTION II - MEDICAL HISTORY(Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.

48. A change of menstrual pattern (other than pregnancy)

50. Any abnormal PAP smear(s)

52. Diagnosed with endometriosis or ovarian cysts

54. Sexually transmitted disease (syphilis, gonorrhea,chlamydia, genital warts, herpes, etc.)

59. Sexually transmitted disease (syphilis, gonorrhea,chlamydia, genital warts, herpes, etc.)

53. Evaluation, treatment or surgery for any other gynecological(female) disorder

51. Date of last PAP smear (YYYYMMDD)

55. First day of last menstrual period (YYYYMMDD)

49. Pregnancy, abortion or miscarriage

CURRENTLY HAVE OR ANY HISTORY OF:FEMALES ONLY:

56. Missing a testicle, testicular implant, or undescended testicle

58. Prostate problems57. Variocele, hydrocele, or any scrotal mass, swelling or pain

MALES ONLY:

60. Missing a kidney

65. Bedwetting or treatment for bedwetting (after childhood)66. Hernia

64. Painful or difficult urination63. Blood or protein in urine

62. Kidney or urinary tract surgery of any kind61. Kidney stone, infection or disease

URINARY SYSTEM

ENDOCRINE AND METABOLIC

67. Recurrent back pain or back problem

71. Abnormal curvature of your spine (any part)70. Back or neck surgery69. Recurrent neck pain68. Herniated disk

SPINE AND SACROILIAC JOINTS

72. Painful shoulder, elbow, wrist, hand or fingers73. Dislocated shoulder, elbow, wrist, hand or fingers

UPPER EXTREMITIES

78. Bone, joint, or other orthopedic deformity79. Loss of finger or toe, or extra finger or toe

87. Any need to use corrective devices such as prostheticdevices, knee brace(s), back support(s), lifts or orthotics

88. Any other orthopedic, muscle, or sports injury problems

86. Pain or swelling at the site of an old fracture85. Plate(s), screw(s), rod(s) or pin(s) in any bone84. Surgery on any joint/bone (including arthroscopy)83. Any swollen joint(s)

82. Arthritis, rheumatism, or bursitis81. Impaired use of arms, hands, legs, or feet (any reason)

80. Loss of the ability to fully flex (bend) or fully extend a finger,toe, or other joint

MISCELLANEOUS CONDITIONS OF THE EXTREMITIES

LEARNING, PSYCHIATRIC, AND BEHAVIORAL131. Evaluated or treated for Attention Deficit Disorder (ADD) or

Attention Deficit Hyperactivity Disorder (ADHD)

133. Diagnosed with a learning disorder, to include dyslexia

135. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or out-patient) including counseling or treatment for school, adjustment, family, marriage, divorce, depression, anxiety, or treatment of alcohol, drug or substance abuse (Applicant or recruiter will request sealed medical supporting documents from health care providers marked "CONFIDENTIAL: MEPS MEDICAL DEPART- MENT" and submit directly to MEPS medical personnel.)

134. Received counseling of any type

132. Taken (or taking) medication, drugs, or any substance to improve attention, behavior, or physical performance

SLEEP DISORDERS

89. High or low blood pressure90. Raynaud's phenomenon or disease

92. Pulmonary embolism (blood clot in lung)91. Deep Vein Thrombosis (blood clot; leg or elsewhere)

VASCULAR

74. Foot trouble(e.g., pain, corns, bunions, warts, ingrowntoenails, etc.)

75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)

77. Dislocated hip, knee, ankle, foot or toes

76. Painful hip, knee, ankle, foot or toes

LOWER EXTREMITIES

93. Acne or psoriasis

96. Large or painful scars97. Any other skin problems

95. Atopic dermatitis94. Eczema

SKIN AND CELLULAR

98. Anemia99. Blood clots requiring blood thinner medicine

101. Prolonged bleeding (after an injury or tooth extraction)102. Any other blood or circulation problems

100. Absence or removal of the spleen

BLOOD AND BLOOD FORMING TISSUES

103. Adverse reaction to medication

105. Allergy to common foods (milk, eggs, fish, meat, etc.)

111. Car, train, sea, or air sickness110. Disorder(s) of your immune system (including HIV)109. Malaria

114. Diabetes or told that you should be tested for diabetes113. High or low blood sugar112. Thyroid trouble or goiter

NEUROLOGIC

117. Taking medication to prevent headaches116. Frequent or severe headaches, including migraines115. Cerebrovascular incident (stroke)

126. Dizziness or fainting spells

127. Any other neurologic problems

125. Seizures, convulsions, epilepsy or fits124. Meningitis, encephalitis, or other neurological problems

130. Sleep apnea or severe snoring129. Frequent trouble sleeping128. Sleepwalking or narcolepsy

123. Paralysis122. Loss of memory or amnesia, or neurological symptoms

121. A period of unconsciousness or concussion120. A head injury, memory loss, or amnesia119. A skull fracture

118. Lost time from work or school due to frequent or severe headaches

108. Positive test for tuberculosis (PPD or blood test)107. Tuberculosis or lived with someone who had tuberculosis

106. Allergy to wool, latex, or other material

104. Adverse reaction to serum, insect stings, or tree nuts

SYSTEMIC

NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NO


(describe reaction in Section III)


SECTION II - MEDICAL HISTORY(Continued). Initial each item "Yes" or "No". All "Yes" items must be fully explained in Section III.

SECTION III - APPLICANT COMMENTS. Explain all "Yes" answers to questions 1 - 164 above. Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs), Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current medical status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical evaluation and treatment records.

CURRENTLY HAVE OR ANY HISTORY OF: NOYESCURRENTLY HAVE OR ANY HISTORY OF:YES NOLEARNING, PSYCHIATRIC, AND BEHAVIORAL (Continued)

141. Anorexia, bulimia, or other eating disorder

145. Used illegal drugs or abused prescription drugs

146. Have you been evaluated, treated, or hospitalized for substance abuse, addiction or dependence (including illegal drugs, prescription medications or other substances)

147. Have you been evaluated, treated, or hospitalized for alcohol abuse, dependence, or addiction

149. Any other learning, psychiatric, or behavioral problems

148. Post-traumatic Stress Disorder or excessive stress requiring counseling and/or medication following a traumatic experience

144. Have you ever attempted or considered suicide143. Have you ever purposely cut or harmed yourself142. Habitual stammering or stuttering

150. Tumor, growth, cyst, or cancer of any type

TUMORS AND MALIGNANCIES

151. Cold injury, frostbite or cold intolerance152. Heat injury, heat stroke or heat intolerance

MISCELLANEOUS

153. Are you taking any medications, to include over the counter medications (OTCs), vitamin, herbal, or nutritional supplements (If "yes", list all in Section III.)

154. Any recent unexplained gain or loss of weight155. Artificial or replacement body part (eye, bone, palate, hip,

knee, joint, leg, arm, etc.)156. Have you ever had any illness or injury other than those

already noted? (If "yes", specify when, where and give details in Section III.)

SUPPLEMENTAL QUESTIONS

157. Have you ever been treated in an Emergency Room? (If "yes", explain in Section III.)

160. Have you ever been rejected for military Service for any reason? (If "yes", give date and reason in Section III.)

161.

162. Have you ever been refused employment or been unable to hold a job or stay in school because of any of the following: (If "yes", answer a - d below and give reasons in Section III.)

163. Applied for and/or received disability evaluation and/or compensation for an injury or other medical conditions (If "yes", provide details in Section III.)

164. Have you ever been denied life insurance? (If "yes", provide reason(s) in Section III.)

a. Sensitivity to chemicals, dust, sunlight, etc.

d. Other medical reasons

c. Inability to stand, sit, kneel, lie down, etc.b. Inability to perform certain motions

159. Have you ever had, or have you been advised to have anyoperations or surgery? (If "yes", describe and give age at which occurred in Section III.)

158. Have you ever been a patient in any type of hospital (including being kept overnight)? (If "yes", specify when, where, why, and name of doctor and complete address of hospital in Section III.)

SUPPLEMENTAL QUESTIONS (Continued)


140. Nervous trouble of any sort (anxiety or panic attacks)

139. Been evaluated or treated, either with medication or counseling, for a mental condition, depression or excessive worry

136. Been expelled or suspended from school

138. Been arrested or other encounters with law enforcement137. Been kicked out or removed from your home

Have you ever been discharged from the military Service for any reason? (If "yes", give date, reason, and type of discharge, whether honorable, other than honorable, for unfitness or unsuitability in Section III.)


SECTION III - APPLICANT COMMENTS (Continued).

SECTION IV - HEALTH CARE PROVIDER/INSURANCE CARRIER CONTACT INFORMATION: Current Primary Care Physician(s)/Practitioner(s) and/or Clinic(s) where care is received and Current/Previous Insurance Carrier(s) information. Attach additional sheets if necessary.

c. TELEPHONE (Include AreaCode)b. ADDRESS (Include ZIP Code)a. NAME(S)1. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)

c. TELEPHONE (Include AreaCode)b. ADDRESS (Include ZIP Code)a. NAME(S)

2. PREVIOUS PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S)

c. TELEPHONE (Include AreaCode)b. ADDRESS (Include ZIP Code)a. NAME(S)

3. CURRENT INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)

c. TELEPHONE (Include AreaCode)b. ADDRESS (Include ZIP Code)a. NAME(S)4. PREVIOUS INSURANCE AND/OR PHARMACY BENEFIT MANAGER(S)


NONE

NONE

NONE

NONE


SECTION V - APPLICANT VALIDATION, AUTHORIZATION AND SIGNATURE

STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES IN SECTION V (BELOW)

I (we) , the undersigned:

Certify the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my physical and mental history.

Authorize and understand that a physical examination is part of the accession evaluation, may require several visits to the Military Entrance Processing Station (MEPS), and that I will have blood work and/or other medical tests, procedures and/or specialty consultations performed as part of my processing. I understand that the results of the examination, tests, and consults will be reviewed and considered as part of my application file and are not performed as part of an individual healthcare treatment plan. The MEPS medical staff are not my healthcare providers. If I do not receive notice of an abnormal test or consult, I am not to assume that the results are normal. Furthermore, if any test or consult results are abnormal, I am responsible for obtaining those results from the MEPS and for any necessary follow-up evaluations and/or treatment. If I am notified to return to the MEPS to discuss medical results, it is my responsibility to take quick action to return to the MEPS to speak with the Chief Medical Officer (CMO). Any concerns that I have about my health and healthcare are my responsibility to address with my personal healthcare provider(s).

Understand that I must provide required documentation regarding my health history which, upon my accession, will become part of my Service member lifecycle medical treatment record.

Authorize the Department of Defense (DoD) to request holders of medical/behavioral health data (including but not limited to healthcare providers, clinics, hospitals, insurance companies, pharmacy benefit managers, pharmacies, health information exchanges, and federal and state agencies) to release to the DoD medical authority a complete transcript of my health data for purposes of processing my application for Military Service. I also authorize holders of my health data to report to the DoD whether any data they hold or have held about me has been amended or restricted. I agree that all personal information or data disclosed by myself or others on my behalf with my consent during this process may be further disseminated as needed during the accession process and that my medical information is no longer protected by federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules.

Authorize release of records and information relating to grades, performance, individual education plans, and disciplinary proceedings. Under the Family Educational Rights and Privacy Act (FERPA) USMEPCOM is authorized to receive all my education/disciplinary records for evaluation of my acceptability for Service in the Armed Forces.

Understand that I have the right to refuse to sign this authorization but also understand that failure to do so may cause me to be found disqualified for further processing.

Understand this authorization will expire two years from the date of the signature below or sooner if written request is received by USMEPCOM Staff Judge Advocate's Office. I have the right to revoke this authorization in writing, except to the extent that the DoD has acted in reliance on this information.

c. DATE SIGNED (YYYYMMDD)b. SIGNATUREa. NAME (Last, First, Middle Initial)

2. PARENT OR GUARDIAN SIGNATURE IS MANDATORY FOR MINOR APPLICANT,SIGNATURE IS OPTIONAL IF APPLICANT IS OF AGE

b. DATE SIGNED (YYYYMMDD)a. SIGNATURE1. APPLICANT

d. DATE SIGNED (YYYYMMDD)c. SIGNATUREb. RECRUITERIDENTIFICATION NUMBER

a. NAME (Last, First, Middle Initial)

3. RECRUITING REPRESENTATIVE: (If a representative was used)I certify all information is complete and true to the best of my knowledge.


Nelson, Jessica A.

20161004

48EAT60


SECTION VI - MEDICAL PROVIDER'S SUMMARY AND DESCRIPTION OF PERTINENT INFORMATION: Review and comment on all medical records, electronically provided medical history information, and other electronic data available in the Department of Defense Accessions Processing System. Medical providers may also develop any additional medical history deemed important and record significant findings here or by interview and document them on DD Form 2808, "Report of Medical Examination". Attach additional sheet(s) if necessary.COMMENTS:

SECTION VII - MEDICAL PROVIDER'S PRESCREEN DETERMINATION BASED ON AVAILABLE INFORMATION:

1.a. DATE (YYYYMMDD)

h. DATE (YYYYMMDD)

b. MEDICAL PROCESSING STATUS

ON EXAM: i. PROVIDER INITIALSd. *AE g. *OEf. *MEe. *REc. NPSb. PSN INCOMa. PSN COMP

PA PULHES SMWRA INPUTCONDITIONICDMETR PNJRJPHPRWd. PROVIDER

INITIALSc. IF NOT WITHIN STANDARDS:

KEY: PA = Processing Authorized; PRW = Processing Requested by SMWRA; PH = Processing Hold; RJ = Return Justified; METR = Medical Evaluation and/or Treatment Records; PNJ = Processing Not Justified; ICD = International Classification of Disease Code; PULHES = P (Physical Capacity), U (Upper Extremities), L (Lower Extremities), H (Hearing), E (Eyes), S (Psychiatric); SMWRA = Service Medical Waiver Review Authority.

KEY: PSN = Prescreen; COMP = Complete; INCOM = Incomplete; NPS = Not Prescreened; AE = Applicant Error; RE = Recruiter Error; ME = MEPS Error; OE = Other Source of Error.

2. *FOR MEPS USE ONLY:

3. AUTHORIZING MEDICAL PROVIDER 4. NUMBER OFADDITIONALSHEETSSUBMITTED

c. DATE SIGNED (YYYYMMDD)b. SIGNATUREa. NAME (Last, First, Middle Initial)


I understand that certain skill areas in the Air Force cannot be performed by persons who have abused drugs or alcohol. My unit commander will have final approval authority regarding my actual assignment to sensitive skill positions. If I am not acceptable for such duties due toinformation I have revealed on this form, I will be reassigned to another position in my skill or reclassified into another skill. If it is establishedthat I have used any substance beyond that which I have indicated on this form, I understand my enlistment, commissioning, or appointment may be declared fraudulent and I may be discharged.

DATE NAME (Last, First, M.I.) AND SSN OF APPLICANT

ADVERSE ADJUDICATION: An adverse adjudication (adult or juvenile)

PRIVACY ACT STATEMENT

dismissed, or acquitted. If the adjudicating authority places a condition or restraint that leads to dismissal, dropped charges, or acquittal, the adjudicationis adverse. Suspension of sentence, pardon, not processed, or dismissal after compliance with imposed conditions is adverse adjudication.

is a finding, decision, sentence, or judgment, other than unconditionally dropped,

AIR FORCE: Includes active Air Force, Air Force Reserve, Air National Guard, and Air Force Academy. ALCOHOL ABUSE:NOTE: When not confirmed by medical authority, self-admitted alcohol use that leads to a person's misconduct or unacceptable behavior; to theimpairment of work performance, physical or mental health, financial responsibility or personal relationships; must be reported during the medical examination for determination of alcohol abuse.

Alcohol use confirmed by competent medical authority that the individual is emotionally, mentally, or physically dependent on alcohol.

DRUG ABUSE: The illegal, wrongful, or improper use of marijuana, any narcotic substance, hallucinogens, or any illegal drug. ILLEGAL DRUGS:Includes, but not limited to: cocaine, crack, hallucinogens,

Any drug or narcotic that is habit forming or has a potential for abuse because of its stimulant, depressant, or hallucinogenic effect.

in non-marijuana form, and others), (to include lysergic acid diethyamide (LSD), phencyclidine (PCP), tetrahydrocannabinal (THC)

opium, morphine, heroin, dilaudid, codeine, Demerol, inhalants (paint, glue, and others), amphetamines (speed),methamphetamines (ice), barbiturates (downers) and anabolic steroids. MARIJUANA:Any intoxicating organic or synthetic cannabis or tetrahydrocannabinal (THC) type substance. Organic forms from the hemp plant include

"KO Knockout 2" or variant thereof by whatsover name it may be called.

marijuana, hashish and all derivatives of cannabis sativa. Synthetically, in the form of an herbal and chemical product which, when consumed mimics theeffects of cannabis, includes salviadivinorum or salvinorum or any product known under such names as "Spice", "Genie", "DaScents", "Zohia", "K-2", and

USAF DRUG AND ALCOHOL ABUSE CERTIFICATE

SECTION I. DEFINITION OF TERMS

SECTION II. CERTIFICATION AT TIME OF APPLICATIONWARNING: YOU MUST BE TOTALLY HONEST IN COMPLETING THIS FORM.action can or will be taken against a civilian applicant as a result of any information you reveal.

If you are truthful now and are accepted by the Air Force, no punitive

PUNITIVE ACTION MAY BE TAKEN AGAINST YOU BASED UPON THE FALSE INFORMATION YOU HAVE PROVIDED.

HOWEVER, YOU ARE CAUTIONED THAT SHOULD YOU CONCEAL DRUG OR ALCOHOL ABUSE INFORMATION AT THIS TIME, AND IT IS DISCOVERED AFTER YOUR ENTRY INTO THE AIR FORCE,

not limited to, elimination from training or discharge under less than honorable conditions. Such action includes, but is

INITIAL YES/NO BOXES AS APPLICABLE YES NO

SECTION III. STATEMENTS OF UNDERSTANDING

During my medical examination I will be tested and screened for drug and alcohol abuse. I understand that any detection of drug use(including marijuana)after entry in the Air Force, and I may be discharged based on the results of such screening.

or alcohol abuse will render me ineligible for the Air Force. I understand I will undergo further drug and alcohol screening

(including marijuana) or any alcohol abuse as described above, FROM THIS DATE FORWARD,considered evidence of my inability to meet the standards of behavior expected of me as a member of the Air Force. Therefore, any drug use

renders me ineligible for the Air Force.

Drug and alcohol abuse by members of the U.S. Air Force violates Air Force standards of behavior and conduct and will not be tolerated. If Iam identified as a drug or alcohol abuser while a member of the Air Force, appropriate disciplinary or administrative action may be takenagainst me, to include trial by court martial or discharge under less than honorable conditions.

SIGNATURE

AF FORM 2030, 20121107

INITIALS

KNOWING AND UNDERSTANDING ALL THE INFORMATION ABOVE, AND REALIZING THAT THIS DOCUMENT WILL BE USED ONLY TODETERMINE MY ELIGIBILITY AND RECORD MY CERTIFICATION OF ELIGIBILITY, I HEREBY STATE THAT THE ABOVE INFORMATION AS TO MYPREVIOUS DRUG OR ALCOHOL INVOLVEMENT IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Have you ever used or experimented with marijuana?

Preservice marijuana use may render you ineligible for certain skills.)

(Prior marijuana use is not disqualifying for enlistment or appointment, unless you aredetermined to be a chronic user or psychologically dependent, have been convicted or adversely adjudicated for marijuana involvement.

I have read and understand the definition of the terms above.

Have you ever been treated or undergone rehabilitation for drug or alcohol abuse?Have you consumed hemp seed oil or any products containing hemp seed oil in the last 45 days?

Have you ever experimented with, used, or possessed any illegal drug or narcotic?Have you ever been a supplier or distributor of or a trafficker in marijuana, or other illegal drugs or narcotics?

PREVIOUS EDITIONS ARE OBSOLETE PRIVACY ACT INFORMATION: The information in this form isFOR OFFICIAL USE ONLY. Protect IAW the Privacy Act of 1974

AUTHORITY: Title 10 U.S.C., Chapter 31, Sections 504, 505, 508, 513; Chapter 807, Section 8067; Chapter 833, Section 8258; Chapter 1205, Sec12201, and Executive Order 9397 (SSN), as amended.

apply.

PURPOSE: To determine enlistment/commissioning eligibility, and process qualified applicants. To determine classification and assignment actions

Service in the United States Air Force places me in a position of special trust and responsibility. Drug or alcohol abuse after this date will be

ROUTINE USES: Disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act outside the DoD as a routine use. 'Blanket Routine Uses'after enlistment or commissioning. All documents are source documents in determining benefits/entitlements.

DISCLOSURE: Voluntary; however, failure to furnish personal identification information my negate the enlistment/commissioning application.

REMARKS

DATE NAME (Last, First, M.I.) AND SSN OF APPLICANT

DATE NAME (Last, First, M.I.) AND GRADE OF WITNESS

SECTION IV. RECERTIFICATION AT TIME OF ENLISTMENT, COMMISSIONING, OR APPOINTMENT

I have read and fully understand all the information on this form.

I hereby state that there has been no change in my status since I originally provided this information on the date on front of thisform.

I hereby certify that I have not used any drug, including marijuana, and that I have not been in any alcohol related abuse incidents,since I originally completed this form.

SIGNATURE

WITNESSI CERTIFY THE ABOVE INDIVIDUAL SIGNED THIS CERTIFICATE OF HIS/HER OWN FREE WILL

SIGNATURE

AF FORM 2030, 20121107 PREVIOUS EDITIONS ARE OBSOLETE PRIVACY ACT INFORMATION: The information in this form isFOR OFFICIAL USE ONLY. Protect IAW the Privacy Act of 1974

INITIALS

DATE NAME (Last, First, M.I.) AND GRADE OF WITNESS


SIGNATURE

DISCLOSURE NOTICE

Fair Credit Reporting Act (15 U.S.C. 1681-1681u)

Under the Federal Fair Credit Reporting Act (FCRA), any consumer reporting agency may furnish a consumer report to employers or prospective employers who intend to use the report for employment purposes if the employer notifies the consumer that a report will be obtained and the consumer provides written authorization.

This document serves as notice to you that the United States Air Force will obtain a consumer report from a consumer-reporting agency to be used for employment purposes. Information in the report may be used alone or in conjunction with other information provided by you to make a determination regarding your eligibility for enlistment into the United State Air Force. Your signature below constitutes authorization for the United States Air Force or its duly authorized representative, to procure a consumer report from a consumer-reporting agency.

In the event you are denied entry, based in whole or in part, on the information contained in the consumer report, you will be provided a description of your rights under the FCRA, and the name, address and telephone number of the consumer reporting agency that furnished the report.

AUTHORIZATION FOR RELEASE OF INFORJ\'lATION

I hereby authorize the United States Air Force or any of its duly authorized representatives, to procure a consumer report for employment purposes from any consumer-reporting agency.

Typed or Printed Name of Applicant

Signature of Applicant Date


AUTIIORITY: 1 U.S.C. 504, 505, 508, 510 and Executive Orders 9397, 10450 PRlNCIP AL PURPOSE: To determine financial qualification for entry into the United States Air Force. This data is FOR OFFICIAL USE ONLY and will be maintained in strict confidence within the Department of Defense according to federal law and regulation. ROUTINE USE: Record is maintained with other enlistment processing records. Disclosure is voluntary; however, failure to provide information necessary to determine your financial qualifications for entry into the United States Air Force could result in denial of enlistment.

FINANCIAL STATUS OF APPLICANT (This /MT Is subject to the Privacy Act of 1974 • Use Blanket PAS· AF /MT 883)

DATE Form Approved OMB NO. 0701-0079 Expires 31 Dec 2006

Public reporting burden for this collectlon of Information Is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the col!ectlon of Information. Send comments regarding this burden estimate or any other aspect of this col!ecUon of Information, Including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Jnformatlon Operations and Reports, (0701-0079), 1215 Jefferson Davls Highway, Suite 1204, Arlington, VA 22202·4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for falling to comply with a collection of Information if it does not display a current valld OMB control number. Please DO NOT RETURN your form to the above address. Return completed form to: HQ USAFRSIRSOPA, Randolph AFB TX 78150-5421. 1. NAME OF APPLICANT (Last, First, Middle /nit/a/) 2. ADDRESS OF DEPENDENTS (ff different from applicant)

3. INCOME a. APPLICANT b. SPOUSE

CURRENT SALARY CURRENT SALARY

AMOUNT OF OTHER INCOME AND SOURCE AMOUNT OF OTHER INCOME AND SOURCE

IF UNEMPLOYED, INDICATE SALARY FOR LAST EMPLOYMENT AND TERMINATION DATE

ANTICIPATED INCOME OTHER THAN MILITARY SALARY IF ENLISTMENT IS APPROVED

4. MONTHLY EXPENSES

RENT/MORTGAGE

UTILITIES

FOOD

MEDICAL

CLOTHING

INSURANCE (Lile)

INSURANCE (Auto)

VEHICLE OPERATING EXPENSES

TOTAL

6.

SAVINGS

BONDS/STOCKS

VEHICLE(S)

AMOUNT 5. OTHER EXPENSES

CREDIT CARD

CREDIT CARD

CREDIT CARD

LOAN

AUTO PAYMENT

CHILD SUPPORT/ALIMONY

OTHER/RECURRING MONTHLY DEBTS

TOTAL

AMOUNT OTHER (Specify)

7. REMARKS {Identify by Item number and continue on reverse If more space /s needed)

MONTHLY PAYMENT

The above is true to the best of my knowledge, and includes all current and known future obligations and/or demands against my income.

SIGNATURE OF APPLICANT SIGNATURE OF RECRUITER

AFRS IMT 1325, 20041101, V1 PREVIOUS EDITION IS OBSOLETE.

BALANCE

AMOUNT

TATTOO SCREENING / VERIFICATION

SECTION I. APPLICANT

AFRS TATTOO FORM 4428, 20110801 PREVIOUS EDITIONS ARE OBSOLETE.

Number on Location Description, Size, Shape and Meaning

SECTION II. IDENTIFICATION

a. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) b. DATE OF BIRTH (YYYYMMDD)

PRIVACY ACT STATEMENTAUTHORITY:

ROUTINE USE(S):

PRINCIPAL PURPOSE(S):

10 USC Sections 133, 265, 275, 504, 508, 510, 672(d), 678, 837, 1007, 1071 through 1480, 1553, 2105, 2107, 3012, 5031, 8013, 8033, 8496, and9411; 32 USC 708; 44 USC 3101; and Executive Orders 9397, 10450, and 11652.

To determine qualification for entry into the US Air Force. This data is FOR OFFICIAL USE ONLY and will be maintained in strictconfidence within the Department of Defense according to Federal law and regulation. If you are accepted and subsequently enter into a component of the AirForce, the information becomes a part of your military personnel records which is used to provide information for personnel management actions. If you are notaccepted or do not subsequently enter a component of the Air Force, your records will be destroyed as specified by regulation.

None.

Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. DISCLOSURE:

The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a$10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a commissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge and could receive a less than honorable service characterization.

WARNING:

INTERNAL USE ONLY

Initials

Mark All Tattoo/Brand location on body with a number and your initialsDescribe tattoo information below for all Tattoos

Front Back

c. SOCIAL SECURITY NUMBER

BodyDiagram

NAME (Last, First, M.I.) AND GRADE OF WITNESS

SECTION VI. RECERTIFICATION AT TIME OF EXTENDED ACTIVE DUTYI hereby state that there are no changes to my status on Section II and that any additional tattoo's or body modifications have beenaccuratly accounted for on this form.

SIGNATURE

CERTIFYING OFFICIALI CERTIFY THE ABOVE INDIVIDUAL SIGNED THIS CERTIFICATE OF HIS/HER OWN FREE WILL

SIGNATURE

INITIALS

SECTION II. TATTOO IDENTIFICATION OVERFLOW

NAME (Last, First, M.I.) AND GRADE OF WITNESS

SECTION V. VALIDATION DURING INITIAL PHYSICAL PROCESSINGI hereby certify that all tattoos, brands and body modifications have been disclosed and are accurately accounted for in Section II. Any additional tattoos, brands and body modifications may result in a possible rejection of my Air Force application.

SIGNATURE

CERTIFYING OFFICIALI CERTIFY THE ABOVE INDIVIDUAL SIGNED THIS CERTIFICATE OF HIS/HER OWN FREE WILL

SIGNATURE

INITIALS

AFRS TATTOO FORM 4428, 20110801 PREVIOUS EDITIONS ARE OBSOLETE.INTERNAL USE ONLY

SECTION III. AIR FORCE TATTOO / BRAND / BODY MODIFICATION POLICY

Unauthorized (content): Tattoos/brands/body markings anywhere on the body that are obscene, commonly associated with gangs, extremist, and/orsupremacist organizations, or that advocate sexual, racial, ethnic, or religious discrimination are prohibited in and out of unifom.

Excessive tattoos/brands will not be exposed or visible (includes visible through the uniform) while in uniform. Excessive is defined as any tattoo/brandsthat exceed 1/4 of the entire (front and back) body part and those above the collar bone that are visible when wearing an open collar shirt, ie. blue shortsleeve uniform shirt. (Tattoo's on the back of the neck must not protrude above the collar when wearing an open collar uniform i.e. BDU/ABU shirt or AFblue shirt).

What is considered an exposed body part? Hands: From wrist to tip of finger. Arms: Approximately one inch above the Forearm to tip of middle finger (withfingers extended). Legs: top of the kneecap to just above the ankle. If the authorized tattoo(s) covers more than 1/4 (25%) of the entire exposed body part the applicant is not qualified to enter the Air Force.

SECTION IV. INITIAL CERTIFICATIONI hereby certify that the markings in section II are a true and accurate representation of all tattoos, brands and body modifications.

I have read and full understand the information contained on this form and have been briefed on the Air Force tattoo, brand and bodymodification policy. I also understand that the Air Force may reject my application due to tattoos, brands or body modifications thatdo not meet the minimum standards.

SIGNATURE

RECRUITERI CERTIFY THE ABOVE INDIVIDUAL SIGNED THIS CERTIFICATE OF HIS/HER OWN FREE WILL

SIGNATURE

INITIALS

DATE

DATE

DATE

DATE

DATE

DATE

There is no additional tattoo/brand/body marking information for this section. Applicants Initials: _____________

NAME (Last, First, M.I.) AND GRADE OF

WITNESS Nelson, Jessica A., E-6

NAME (Last, First, M.I.) AND SSN OF APPLICANT

NAME (Last, First, M.I.) AND SSN OF APPLICANT G

1297613185A

Typewritten Text

AFRS TATTOO FORM 4428, 20110801 PREVIOUS EDITIONS ARE OBSOLETE.INTERNAL USE ONLY

SECTION II. TATTOO IDENTIFICATION OVERFLOW (CONT)a. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX) b. DATE OF BIRTH c. SOCIAL SECURITY NUMBER(YYYYMMDD)

There is no additional tattoo/brand/body marking information for this page. Applicants Initials: _____________

RECRUIT/TRAINEE PROHIBITED ACTIVITIES ACKNOWLEDGMENT

INSTRUCTIONSIn accordance with DoDI 1304.33, this form will be read and signed no later than the first visit with a recruiter following a recruit's entry into the Delayed Entry Program or read and signed no later than the first day of entry-level training for a trainee. As a minimum, the signed original will be retained in the recruit's file until they enter active duty or in the trainee's file until they detach from the training command or school they are attending. Please initial beside each entry acknowledging that you have read and understand the statement.

1. RECRUIT/TRAINEE NAME (Last, First, Middle)

4. RECRUITING OFFICE/TRAINING COMMANDADDRESS (City, State, ZIP Code)

5. DATE SIGNED(YYYYMMDD)

2. PAY GRADE 3. RECRUITING OFFICE/TRAINING COMMAND

6. SIGNATURE

7. I ACKNOWLEDGE AND UNDERSTAND THAT AS A RECRUIT OR TRAINEE, I WILL NOT:

10. APPROVED BY

(Initial) a. Develop, attempt to develop, or conduct a personal, intimate, or sexual relationship with a recruiter or trainer.This includes, but is not limited to, dating, handholding, kissing, embracing, caressing, and engaging in sexualactivities. Prohibited personal, intimate, or sexual relationships include those relationships conducted in person orvia cards, letters, e-mails, telephone calls, instant messaging, video, photographs, social networking, or any othermeans of communication.

b. Establish a common household with a recruiter/trainer, that is, share the same living area in an apartment, house,or other dwelling.

f. Gamble with a recruiter/trainer.

h. Lend money to, borrow money from, or otherwise become indebted to a recruiter/trainer.

g. Make sexual advances toward, or seek or accept sexual advances or favors from, a recruiter/trainer.

e. Allow entry of any recruiter/trainer in my dwelling or privately-owned vehicle except to conduct official business.Exceptions are permitted for official business when the safety or welfare of the recruiter/trainer is at risk.

d. Attend social gatherings, clubs, bars, theaters or similar establishments on a personal social basis with a recruiter/trainer.

c. Consume alcohol with a recruiter/trainer on a personal social basis.

8. EXCEPTIONS. Exceptions may be granted to accommodate relationships that existed prior to the start of the recruiting process or

DESCRIPTION OF EXCEPTION(S):

a. NAME (Last, First, Middle Initial) d. SIGNATURE/RANKb. TITLE c. DATE SIGNED (YYYYMMDD)

DD FORM 2983, JAN 2015 Adobe Designer 9.0

9. VIOLATIONS. Violations of any part of paragraph 7.a. through 7.h., not granted an exception in paragraph 8, mayresult in disciplinary action.

(Initial)

AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Instruction 1304.33, Standardized Protection Policies Prohibiting Inappropriate Relations Between Recruiters and Recruits, and Trainers and Trainees.PRINCIPAL PURPOSE(S):ROUTINE USE(S):

To document your understanding of the prohibitions identified in section 7 of this form.The DoD Blanket Routine Uses found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx

apply to this collection.DISCLOSURE: Voluntary. However, if you fail to provide the requested information or complete this form, you might not be able to complete your enlistment or receive training.


prior to the trainee starting the formal training process. These relationships include, but are not limited to, family members. Onlythe Recruit's or Trainee's Commander, O-4 or higher, or higher level authority, has the authority to approve these exceptions.Approved exceptions will be documented below and signed by the Recruit's or Trainee's Commander, O-4 or higher, or a higher-level authority.

O-1 H3E/AETC

333 Sunset Avenus Ste.200, Suisun City, CA 94585

ning l uct is

ETELY.

NO

AFRS FM 6C, 20130410, V2 PREVIOUS EDITIONS ARE OBSOLETE.

RECRUITING PROCESS MEPS QUESTIONNAIRE(This form is subject to the Privacy Act of 1974, Use AF Form 883)

The Air Force must recruit and retain the best talent to ensure we continue to be the best Aerospace Force in the world. Measuring professional and unprofessional conduct is an important facet to ensure we maintain good order and discipline. An environment that tolerates any unprofessional conduct is not conducive to retai the desired talent needed by the United States Air Force. Our goal is to ensure the best working environment possible free from all unprofessional conduct, unlawfu harassment, sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature. You should never feel that submission to such cond needed or a condition of employment. THIS QUESTIONNAIRE WILL BE USED TO IMPROVE RECRUITING EXPERIENCES. PLEASE ANSWER EACH QUESTION HONESTLY AND COMPL

INITIAL YES/NO BOXES AS APPLICABLE (Please provide an explanation to questions answered yes except questions 1-4 in remarks section) YES

1. Did you watch the professional relationship video and receive the Applicant Rights card from your recruiter

2. Do you understand that you are obligated to report any inappropriate conduct from your recruiter or any military or DOD personnel?

3. Would you recommend your recruiter to your friends, family or relative? If Not, please explain.

4. Did your recruiter ensure your process went smoothly and answer all your questions?

5. Did you feel uncomfortable in any way during the application process?

6. During your application process were you asked to do anything that you felt was uncomfortable or awkward?

7. Did your recruiter establish, develop, attempt to develop, or conduct a personal, intimate, or sexual relationship with you? 8. Did your recruiter ever use his or her rank or position to threaten, pressure or promise you favorable treatment in return for personal favors?

(Personal favors are those that are beneficial to the Air Force member and not the United State Air Force. Example: Auto Repair, etc.) 9. Has your recruiter ever touched you inappropriately/suggestively?10. Have you engaged with dating, handholding, kissing, embracing, caressing or participated in sexual activities with your recruiter?11. Has your recruiter ever used sexual innuendos around you? 12. Has your recruiter ever implied or offered favors in exchange for physical contact? 13. Has your recruiter provided alcohol to, or consumed alcohol with you, to include interacting with you at clubs, bars, or theaters on a personal

social basis?14. During your recruiting process, was there anything that we could have done better? If so, explain. 15. Did you receive a copy of, and training covering the material found in the Professional Airman Development Guide (PADG)? (EAD only) 16. Circle all that describe your relationship with your recruiter: A) Friend B) Mentor C) Supervisor D) GuideE) Individual who facilitated my enlistment

REMARKS

APPLICANTI hereby voluntary and of my own free completed this questionnaire without being subjected to any coercion, unlawful influence, or unlawful inducement. I swear (or affirm) I have completed this form and is true and correct to the best of my knowledge.

DATE NAME (Last, First, M.I.) AND SSN OF APPLICANT SIGNATURE


DATE NAME (Last, First, M.I.) AND GRADE OF WITNESS SIGNATURE

Please watch this video pertaining to question 1 on the Recruiting Process MEPS form: https://www.youtube.com/watch?v=wfuK2qqDZT4

UNITED STATES AIR FORCE HEALTH PROFESSIONS

Dear Evaluator,

This individual is applying for a position in the US Air Force. They have chosen you to provide them with a Letter of Recommendation (LOR) due to your familiarity with their character, work ethic and future potential as a military leader. The Air Force Health Professions Scholarship Board places great emphasis on your LOR’s when determining selection.

Please rate this individual with his/her peers with the same experience level. Your full and extended appraisal of this individual’s abilities, accomplishments, attitude, character, integrity, etc. is of the up-most importance to their chances of receiving one of these prestigious slots.

The following are the suggested guidelines;

- Letter should be on official letter-head - Address it to, “Dear Board Members” - Provide a signature and contact information - Should be one complete page - First paragraph to quantify who you are and your position - Next several paragraphs should reflect your opinions on the individual’s

positive traits, talents and potential

Your letters will be held in the strictest of confidence and will be available to myself and the selection board for their consideration of this application.

If you have any questions or concerns, please feel free to call me. A prompt response will ensure our applicant receives the best care possible with their application! Thank you in advance for your time and consideration.

Sincerely,

Jessica A. Nelson, TSgt, USAF

Health Professions Advising

Send LOR’s to: [email protected] Jessica Nelson333 Sunset AveSuite 200Suisin City, CA, 94585

Attachment 8

Applicant Questionnaire

John A. Doe

123 ABC Lane

City, State, Zip Code

HP: (210) 123-4567

1. Why did you choose this specialty/profession?

2. What do you believe are your most significant accomplishments?

3. Identify any significant awards, scholarships or other recognition's you have received.

4. Describe any community service activities, including positions held and responsibilities.

5. List any research, publications or teaching experiences you have accomplished.

6. Would you like to provide the selection board with any further information on specific

aspects of your academic record or application file?

7. What are your long term goals?

8. What do you find appealing about Air Force Health Professions?

9. Why should you be selected? What do you have to offer the Air Force?

(2 part question)

10. What is your current fitness routine? Are you familiar with Air Force Fitness

requirements?

----Applicant’s signature & date signed----

Instructions:1.7. Applicant Questionnaire. With the exception of matrix-qualified MC HPSP, applicants must complete an applicant questionnaire (Attachment 8). Each questionnaire must be written in the attached format, be typed on plain bond paper, and be no longer than two typewritten pages (Size 12-Times New Roman font). Please keep in mind that the questions should be included as a “header”, with the answer just beneath the question itself. To project the most professional image, applicants should pay attention to grammar, spelling, and punctuation as board members thoroughly review the questionnaire.

*You can stretch your margins for extra space if needed

Documents

I am located in Suisun - Davis Pre-Dental Society - · PDF fileJessica Nelson and I am your local Air Force Health Professions Career Advisor. I am located in Suisun City, ... Form